Loss Of Residual Kidney Function Research Articles

#1647 Clinical insights into incremental hemodialysis: a retrospective analysis of patient persistence and outcomes

Abstract Background and Aims Incremental haemodialysis has been proposed as an alternative to standard thrice-weekly haemodialysis for incident patients with significant residual kidney function. Definition is not unique, but it is mostly intended as twice weekly dialysis. Its diffusion is not known since there are no public registers in Europe, but it is adopted in some dialysis facilities, while in others is not, with geographical differences. In our centre incremental haemodialysis in adopted for some patients, based on the clinical judgement, without a strict protocol. We retrospectively analysed clinical outcomes of the incident patients of the last 36 months, to understand which patients may benefit more from this approach, how long it is viable and the clinical outcomes. Method Retrospective observational analysis of incident patients of the last 36 months, without serious rapidly evolving disease. Focus was on persistence in twice-weekly dialysis, nutritional parameters, residual kidney function, hospital admissions and economic considerations. 36 patients started haemodialysis with a 2-times per week schedule while 13 with full dose dialysis. At baseline, there were no significant differences on age, sex, serum albumin or vascular access. 5 patients in full dose group were anuric for bilateral nephrectomy or rapidly progressive kidney disease, while all patients in incremental group had significant residual kidney function (average creatinine clearance: 7.1 ml/min). Results During the follow up period, 19/36 patients’ weekly dialysis sessions were incremented to three after a median time of 280 days, and 17/36 were still on 2-dialysis with a median follow-up time of 228 days. The reason for transition to three dialysis per week was residual kidney function loss except for a case of pericarditis. Persistence in incremental dialysis was >80% at 6 months and 44% at 1 year (Fig. 1a). We observed a significantly reduced persistence in patients with low ultrafiltration at 2nd month of dialysis (<1.7% of weight per session – 1 kg for a 60 kg patient-) and a reduced persistence with pre-dialysis systolic blood pressure <150 mmHg at 2nd month (Fig. 1b-c). Persistence was not different in more frail patients (elderly, dialyzed with a central venous line or with lower baseline albumin). Serum albumin increase was higher in patients in incremental haemodialysis at 6 months, with a borderline statistically significant difference, and similar at 1 year (Fig. 2a-b). The average weight was stable in both groups (Fig. 2). Hospital admissions were lower in the incremental group, and number of days of hospitalization per 1000 patients’ days were lower (24 vs 41 days). Thanks to the incremental approach, about 1600 dialysis sessions were avoided for the patients included in the analysis, with significant reduction of economic impact for the public healthcare and the possibility to treat more patients. Data was insufficient to make conclusions on kidney function preservation. Conclusion Incremental approach is valid in our experience. These data give useful information on how long we can expect patients to persist in 2-weekly dialysis and on which patients might benefit more and longer of this approach. The patients with better volume control, which reflect in adequate blood pressure control and low ultrafiltration rate, show a significantly longer persistence in incremental dialysis. The approach is valid also for frail patients. We also found better albumin and lower hospital admission rates that could be related with a reduced health-care exposition and better overall patients’ well-being, with adequate uremic symptoms control. The reduction on the hospital admissions has been already observed, while the albumin better rise is a new finding and should be confirmed in a randomized or at least larger study. Waiting for the results of the on-going randomized clinical trials, incremental haemodialysis might be the new standard-of-care for a subset incident haemodialysis patients.

Native nephrectomy in polycystic kidney disease patients on transplant lists: how and when?

Autosomal dominant polycystic kidney disease (ADPKD), the most common hereditary kidney disease, accounts for approximately 10% of the patients on kidney transplantation waitlists.High rates of complications including hemorrhage, infections, nephrolithiasis and kidney size-related compressive complaints have been reported among ADPKD patients. Therefore, the need for routine native nephrectomy and timing of such procedure in ADPKD patients being prepared for transplantation are debated. Even though pre-transplant nephrectomy has the potential to provide fewer infectious complications due to lack of immunosuppressive medication use, such procedure has been associated with longer hospital stay, loss of residual kidney function and need for dialysis. Although simultaneous nephrectomy and transplantation could potentially lead to longer perioperative duration, perioperative complications and need for blood transfusions, this was not confirmed in cohort studies. Therefore, some institutions routinely perform simultaneous unilateral nephrectomy and kidney transplantation. In this narrative review, our aim is to evaluate the current evidence regarding the need andtiming of nephrectomy in ADPKD patients in relation to kidney transplantation.

A time-averaged serum bicarbonate-based nomogram to predict the probability of residual kidney function preservation for patients undergoing peritoneal dialysis.

Residual kidney function (RKF) is an important prognostic indicator in peritoneal dialysis (PD) patients. So far, there are no prediction tools available for RKF, and the association between serum bicarbonate and RKF has received little attention in patients with PD. We aimed to develop a nomogram for the preservation of RKF based on the time-averaged serum bicarbonate (TA-Bic) levels. A prediction model was established by conducting a retrospective cohort study of 151 PD patients who had been treated at the First Affiliated Hospital of Anhui Medical University. The nomogram was developed using a multivariate Cox regression model. The discrimination, calibration, and clinical utility of the model were evaluated by the C-index, receiver operating curve (ROC) curve, calibration curve, and decision curve analysis. In the elderly PD onset, higher baseline values of residual glomerular filtration rate, total Kt/V and higher TA-Bic levels were identified as protective predictors of RKF loss. The nomogram was conducted on the basis of the minimum value of the Akaike Information Criterion and Bayesian Information Criterion with a reasonable C-index of 0.766, showing great discrimination, proper calibration, and high potential for clinical practice. Through the total score of the nomogram, the patients were classified into the high-risk group and low-risk group, and a higher cumulative incidence of complete RRF loss was found in the high-risk group compared with the patients in the low-risk group. The novel predictive nomogram model can predict the probability of RKF preservation in long-term PD patients with high accuracy. Future studies are needed to externally validate the current nomogram before clinical application.

Incremental versus conventional haemodialysis in end-stage kidney disease: a systematic review and meta-analysis.

Appropriate dialysis prescription in the transitional setting from chronic kidney disease to end-stage kidney disease is still challenging. Conventional thrice-weekly haemodialysis (HD) might be associated with rapid loss of residual kidney function (RKF) and high mortality. The benefits and risks of incremental HD compared with conventional HD were explored in this systematic review and meta-analysis. We searched MEDLINE, Scopus and Cochrane Central Register of Controlled Trials up to April 2023 for studies that compared the impacts of incremental (once- or twice-weekly HD) and conventional thrice-weekly HD on cardiovascular events, RKF, vascular access complications, quality of life, hospitalization and mortality. A total of 36 articles (138939 participants) were included in this meta-analysis. The mortality rate and cardiovascular events were similar between incremental and conventional HD {odds ratio [OR] 0.87 [95% confidence interval (CI)] 0.72-1.04 and OR 0.67 [95% CI 0.43-1.05], respectively}. However, hospitalization and loss of RKF were significantly lower in patients treated with incremental HD [OR 0.44 (95% CI 0.27-0.72) and OR 0.31 (95% CI 0.25-0.39), respectively]. In a sensitivity analysis that included studies restricted to those with RKF or urine output criteria, incremental HD had significantly lower cardiovascular events [OR 0.22 (95% CI 0.08-0.63)] and mortality [OR 0.54 (95% CI 0.37-0.79)]. Vascular access complications, hyperkalaemia and volume overload were not statistically different between groups. Incremental HD has been shown to be safe and may provide superior benefits in clinical outcomes, particularly in appropriately selected patients. Large-scale randomized controlled trials are required to confirm these potential advantages.

Loss of Residual Kidney Function at One Year in Diabetic and Non-Diabetic Incident Patients Treated with Incremental Hemodialysis

Loss of Residual Kidney Function at One Year in Diabetic and Non-Diabetic Incident Patients Treated with Incremental Hemodialysis

An analysis of the relationship of bloodpressure and its variability withresidual kidney function loss inhemodialysis patients.

This study aims to investigate the relationship of blood pressure (BP) and systolic BP (SBP) variability with residual kidney function (RKF) loss in hemodialysis (HD) patients. The demographic and clinical information and data on RKF loss events in HD patients were collected. The baseline characteristics of the patients were compared among groups according to pre- and postdialysis SBP (< 120, 120-139, 140-159, and ≥ 160 mmHg) and diastolic BP (DBP) (< 80, 80-89, 90-99, and ≥1 00 mmHg). Participants were divided into two groups based on the mean intradialytic and interdialytic SBP variability. Kaplan-Meier analysis and Cox regression analysis were used to evaluate the risk of RKF loss. A total of 157 participants with an average HD vintage of 35.97 months were included. The group with the lowest predialysis SBP showed the longest duration of residual urine. However, Kaplan-Meier analysis and Cox regression analysis indicated that BP and SBP variability were not independent risk factors for RKF loss. Higher serum albumin levels showed protective effects against RKF loss, and diabetes mellitus (DM) and higher serum calcium were the independent risk factors for RKF loss. BP and SBP variability were not independent risk factors for RKF loss in HD patients. DM, serum albumin, and calcium were independent factors related to RKF loss.

Residual Kidney Function and Cause-Specific Mortality Among Incident Hemodialysis Patients

The survival benefit of residual kidney function (RKF) in patients on hemodialysis is presumably due to enhanced fluid management and solute clearance. However, data are lacking on the association of renal urea clearance (CLurea) with specific causes of death. We conducted a longitudinal cohort study of 39,623 adults initiating thrice-weekly in-center hemodialysis from 2007 to 2011 and had data on renal CLurea and urine volume. Multivariable cause-specific proportional hazards model was used to examine the associations between baseline RKF and cause-specific mortality, including sudden cardiac death (SCD), non-SCD cardiovascular death (CVD), and non-CVD. Restricted cubic splines were fitted for change in RKF over 6 months after initiating hemodialysis. Among 39,623 patients with data on baseline renal CLurea and urine volume, there was a significant trend toward a higher mortality risk across lower RKF levels, irrespective of cause of death in a case-mix adjustment model (Ptrend< 0.05). Adjustment for ultrafiltration rate (UFR) slightly attenuated the association between low renal CLurea and high cause-specific mortality, whereas adjustment for highest potassium did not have substantial effect. Among 12,169 patients with data on change in RKF, a 6-month decline in renal CLurea showed graded associations with SCD, non-SCD CVD, and non-CVD risk, whereas the graded associations between faster 6-month decline in urine output and higher death risk were clear only for SCD and non-CVD. Lower RKF and loss of RKF were associated with higher cause-specific mortality among patients initiating thrice-weekly in-center hemodialysis.

Bio-impedance spectroscopy added to a fluid management protocol does not improve preservation of residual kidney function in incident hemodialysis patients in a randomized controlled trial

Avoiding excessive dialysis-associated volume depletion may help preserve residual kidney function (RKF). To establish whether knowledge of the estimated normally hydrated weight from bioimpedance measurements (BI-NHW) when setting the post-hemodialysis target weight (TW) might mitigate rate of loss of RKF, we undertook an open label, randomized controlled trial in incident patients receiving HD, with clinicians and patients blinded to bioimpedance readings in controls. A total of 439 patients with over 500 ml urine/day or residual GFR exceeding 3 ml/min/1.73m2 were recruited from 34 United Kingdom centers and randomized 1:1, stratified by center. Fluid assessments were made for up to 24 months using a standardized proforma in both groups, supplemented by availability of BI-NHW in the intervention group. Primary outcome was time to anuria, analyzed using competing-risk survival models adjusted for baseline characteristics, by intention to treat. Secondary outcomes included rate of RKF decline (mean urea and creatinine clearance), blood pressure and patient-reported outcomes. There were no group differences in cause-specific hazard rates of anuria (0.751; 95% confidence interval (0.459, 1.229)) or sub-distribution hazard rates (0.742 (0.453, 1.215)). RKF decline was markedly slower than anticipated, pooled linear rates in year 1: -0.178 (-0.196, -0.159)), year 2: -0.061 (-0.086, -0.036)) ml/min/1.73m2/month. Blood pressure and patient-reported outcomes did not differ by group. The mean difference agreement between TW and BI-NHW was similar for both groups, Bioimpedance: -0.04 kg; Control: -0.25 kg. Thus, use of a standardized clinical protocol for fluid assessment when setting TW is associated with excellent preservation of RKF. Hence, bioimpedance measurements are not necessary to achievethis.

Impact of incremental initiation of haemodialysis on mortality: a systematic review and meta-analysis.

Incremental haemodialysis initiation entails lower sessional duration and/or frequency than the standard 4 h thrice-weekly approach. Dialysis dose is increased as residual kidney function (RKF) declines. This systematic review evaluates its safety, efficacy and cost-effectiveness. We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library databases from inception to 27 February 2022. Eligible studies compared incremental haemodialysis (sessions either fewer than three times weekly or of duration <3.5 h) with standard treatment. The primary outcome was mortality. Secondary outcomes included treatment-emergent adverse events, loss of RKF, quality of life and cost effectiveness. The study protocol was prospectively registered. Risk of bias assessment used the Newcastle-Ottawa Scale and the revised Cochrane risk of bias tool, as appropriate. Meta-analyses were undertaken in Review Manager, Version 5.4. A total of 644 records were identified. Twenty-six met the inclusion criteria, including 22 cohort studies and two randomized controlled trials (RCTs). Sample size ranged from 48 to 50596 participants (total 101476). We found no mortality differences (hazard ratio=0.99; 95% CI 0.80-1.24). Cohort studies suggested similar hospitalization rates though the two small RCTs suggested less hospitalization after incremental initiation (relative risk=0.31; 95% CI 0.18-0.54). Data on other treatment-emergent adverse events and quality of life was limited. Observational studies suggested reduced loss of RKF in incremental haemodialysis. This was not supported by RCT data. Four studies reported reduced costs of incremental treatments. Incremental initiation of haemodialysis does not confer greater risk of mortality compared with standard treatment. Hospitalization may be reduced and costs are lower.

Evaluation of trough-based vancomycin therapy in achieving targeted area under the curve in haemodialysis cases.

Background &amp; Objectives: Recently published IDSA guidelines on vancomycin dosing no longer advocates the use of trough concentrations as surrogate markers for clinical efficacy. Protocols developed prior to revised targets may not reflect to the true efficacy marker for vancomycin that is AUC/MIC 400-600. This study aimed to evaluate the local vancomycin dosing protocol in achieving the target trough concentration and extrapolated AUC/MIC of 400-600 in patients with haemodialysis.&#x0D; Methods: A retrospective analysis of therapeutic drug monitoring forms and individual medical records of haemodialysis patients was conducted. Vancomycin AUC of each individual was extrapolated via the use of a pharmacokinetic modelling software, PrecisePK®. Chi-square test of independence was used to determine the association of factors affecting AUC/MIC. A p value of 0.05 was considered statistically significant.&#x0D; Results: A total number of 80 haemodialysis-dependent cases who were on vancomycin were recruited. More than 62% of haemodialysis patients showed AUC/MIC &gt; 800. AUC/MIC was heavily influenced by minimum inhibitory concentration of the infecting microorganism. Interpretation &amp; Conclusions: Exclusive trough-guided dosing may not translate well in achieving clinical efficacy of vancomycin in haemodialysis patients. Other contributing factors, especially MIC should be factored, as small MIC values account for greater reciprocal AUC/MIC values that increase the risk of loss of residual kidney function; a factor which is associated with overall mortality of HD patients.

The safety and urate-lowering efficacy of febuxostat in patients undergoing peritoneal dialysis: a retrospective single-arm cohort study of 84 patients.

Studies have shown that hyperuricemia (HUA) is an independent risk factor for all-cause death and residual kidney function loss in peritoneal dialysis (PD) patients. The control of blood uric acid (UA) is an important link to improve the prognosis of end-stage renal disease (ESRD). As a therapeutic drug for HUA, febuxostat is rarely studied in PD patients. The purpose of our study is to investigate the safety, efficacy, and effect on residual renal function (RRF) of febuxostat in patients undergoing PD. This is a retrospective single-arm cohort study. During the study period which from September 2016 to November 2020, 191 patients underwent PD at this hospital. Among these patients, 84 were administrated for over a period of 3 months and were eventually included. These 84 patients (51 males and 33 females; average age: 55.18 years) were undergoing PD complicated with HUA or gout who received febuxostat during a regular follow-up from January 2018 to November 2020. Serum UA (sUA) levels, blood routine, liver function, and RRF were compared before and after febuxostat administration. Adverse events (AEs) resulting from febuxostat treatment were collected from medical records. All 84 patients were administered febuxostat for over 3 months, including 39 for over 6 months and 26 for over 12 months. Some 60 patients were treated with febuxostat dose of 20 mg/day and the remaining 24 patients received 40 mg/day. Compared with pretreatment level, the mean sUA level was observed to be markedly reduced at 1 month after febuxostat administration (320.2±87.27 vs. 498.8±81.47 µmol/L, P<0.0001) and at 3 months (291.6±82.66 vs. 498.8±81.47 µmol/L, P<0.0001) and subsequently remained at a significantly low level for 12 months. Only 5 patients stopped febuxostat because of its associated AEs. An initial dose of 40 mg/day was associated with a higher rate of AEs compared with dose of 20 mg/day (25% vs. 18.33%, respectively). After febuxostat treatment, no significant differences were observed between RRF in the two groups. Febuxostat may be safe and efficient in patients undergoing PD and may not impair RRF. Febuxostat administration at dose of 20 mg/day may be an appropriate dose for patients undergoing PD.

MO476: Prevalence of Symptoms in End Stage Renal Disease and Their Association With Quality of Life

Abstract BACKGROUND AND AIMS End-stage chronic renal disease (ESRD) is an irreversible disease with serious consequences for the life of the patient and perceived as a social and professional handicap. Management of ESRD therefore requires not only control of symptoms and morbidity, but also improvement in the quality of life (QoL) of these patients. Due to its wide variety of symptoms as well as the cost/dialysis patient, ESRD is one of the most expensive pathologies in the world, making it the subject of several studies. The aim of this study was to study the prevalence and influence of symptoms on the physical and mental components of the QoL in patients with ESRD, both in those on pre-dialysis as well as in those already at the stage of hemodialysis. METHOD This is a cross-sectional observational study carried out between January and April 2021. This multicenter study concerned a cohort of 245 patients with end-stage chronic renal failure on dialysis or on pre-dialysis. Upon entry into the study, a set of 17 symptoms was collected by patient interview or by patient self-administered questionnaire. Patients’ QOL was assessed using the physical (PCS) and mental (MCS) summary components of the `Kidney Disease Quality of Life Short Form’ (KDQoL SF-36). Single and multiple logistic and linear regression analyzes were used to compare symptoms and their impact on QoL between predialysis and dialysis. A P-value &amp;lt; .05 in a confidence interval &amp;gt;95% is considered statistically significant. RESULTS Among the 245 patients included, 102 were on pre-dialysis and 143 were in the hemodialysis stage. The mean age of all of our patients was 54.21 ± 11.07 years old with extremes of 19–81 years old and predominantly male (63%). Causal nephropathy was undetermined in 53% of cases; 44% of our patients had hypertension under treatment, and 38% were diabetic. The most common symptoms are sleep disorders (71%), anorexia (48%), muscle pain (26%), weight loss (26%), loss of autonomy and chest pain (21%), asthenia and then libido disorders (20%). Among our patients, 46% still had residual kidney function. Only cramps and fatigue were significantly associated with a decline in kidney function. Symptoms such as asthenia, sleep disturbances, along with restless legs syndrome and pruritus were significantly different in the two groups, being more common in dialysis patients. In univariate analysis, the comparative study of the different components of the score found a statistically significant association between the mental component of the scoring and the age, the female sex, the feeling of burden in relation to the family, the quality of dialysis (Kt/V) and pruritus. In contrast, the duration of kidney disease, loss of residual kidney function and anemia were associated with increased kidney disease burden and physical component. In multivariate analysis, the presence of cardiovascular disease increased the risk of clinically poor QoL, and age &amp;gt;60 years increased the risk of having poor QoL. On the contrary, having the ability to do the work at home as well as a good relationship with caregivers are factors of good QoL mentally, and seniority in HD &amp;gt; 5 years had a positive impact on physical QoL. CONCLUSION The QoL during ESRD is a complex notion that results from an interaction of several components: the disease itself, the patient's psychological traits, the patient's behavior in the face of his illness and social support. Despite this complexity, it must be considered as a criterion for evaluating the means of substitution offered in IRCT. Finally, the QoL after kidney transplant remains much higher than that offered by dialysis despite the risk of complications related to immunosuppressants.

POS-731 INFLUENCING FACTORS FOR RESIDUAL KIDNEY FUNCTION IN INCIDENT PERITONEAL DIALYSIS PATIENTS: A META-ANALYSIS OF OBSERVATIONAL STUDIES

Decline and loss of residual kidney function (RKF) are known to affect life quality of peritoneal dialysis (PD) patients. Whereas influencing factors for RKF in incident PD patients has not been quantitatively estimated. This systematic review and meta-analysis set out to determine the influencing factors including risk and protective factors of residual kidney function decline and loss in incident PD patients.

Benefits of Incremental Hemodialysis Seen in a Historical Cohort Study.

PurposePrevious research on incremental hemodialysis transition has mainly focused on one or two benefits or prognoses. We aimed to conduct a comprehensive analysis by investigating whether incremental hemodialysis was simultaneously associated with adequate dialysis therapy, stable complication indicators, long-lasting arteriovenous vascular access, and long-lasting preservation of residual kidney function (RKF) without increasing mortality or hospitalization.Patients and MethodsIncident hemodialysis patients from Huashan Hospital in Shanghai, China, over the period of 2012 to 2019, were enrolled and followed every three months until death or the time of censoring. Changes in complication indicators from baseline to all post-baseline visits were analyzed by mixed-effects models. The outcomes of RKF loss, arteriovenous vascular access complications, and the composite of all-cause mortality and cardiovascular events were compared between incremental and conventional hemodialysis by Cox proportional hazards model.ResultsOf the 113 patients enrolled in the study, 45 underwent incremental and 68 conventional hemodialysis. There were no significant differences in the changes from baseline to post-baseline visits in complication indicators between the two groups. Incremental hemodialysis reduced the risks of RKF loss (HR, 0.33; 95% CI, 0.14–0.82), de novo arteriovenous access complication (HR, 0.26; 95% CI, 0.08–0.82), and recurrent arteriovenous access complications under the Andersen–Gill (AG) model (HR, 0.27; 95% CI, 0.10–0.74) and the Prentice, Williams and Peterson Total Time (PWP-TT) model (HR, 0.31; 95% CI, 0.12–0.80). There were no significant differences in all-cause hospitalization or the composite outcome between groups.ConclusionIncremental hemodialysis is an effective dialysis transition strategy that preserves RKF and arteriovenous access without affecting dialysis adequacy, patient stability, hospitalization risk and mortality risk. Randomized controlled trials are warranted.

A multicenter feasibility randomized controlled trial to assess the impact of incremental versus conventional initiation of hemodialysis on residual kidney function

Twice-weekly hemodialysis, as part of incremental initiation, has reported benefits including preservation of residual kidney function (RKF). To explore this, we initiated a randomized controlled feasibility trial examining 55 incident hemodialysis patients with urea clearance of 3 ml/min/1.73 m2 or more across four centers in the United Kingdom randomized to standard or incremental schedules for 12 months. Incremental hemodialysis involved twice-weekly sessions, upwardly adjusting hemodialysis dose as RKF was lost, maintaining total (Dialysis+Renal) Std Kt/V above 2. Standard hemodialysis was thrice weekly for 3.5-4 hours, minimum Dialysis Std Kt/V of 2. Primary outcomes were feasibility parameters and effect size of group differences in rate of loss of RKF at six months. Health care cost impact and patient-reported outcomes were explored. Around one-third of patients met eligibility criteria. Half agreed to randomization; 26 received standard hemodialysis and 29 incremental. At 12 months, 21 incremental patients remained in the study vs 12 in the standard arm with no group differences in the urea clearance slope. Ninety-two percent of incremental and 75% of standard arm patients had a urea clearance of 2 ml/min/1.73 m2 or more at six months. Serious adverse events were less frequent in incremental patients (Incidence Rate Ratio 0.47, confidence interval 0.27-0.81). Serum bicarbonate was significantly lower in incremental patients indicating supplementation may be required. There were three deaths in each arm. Blood pressure, extracellular fluid and patient-reported outcomes were similar. There was no signal of benefit of incremental hemodialysis in terms of protection of RKF or Quality of Life score. Median incremental hemodialysis costs were significantly lower compared to standard hemodialysis. Thus, incremental hemodialysis appears safe and cost-saving in incident patients with adequate RKF, justifying a definitive trial.

Contextualizing the FHN Nocturnal Trial a Decade Later: How Nocturnal Home Hemodialysis Is Performed Matters to Outcomes.

Long, frequent hemodialysis (HD) was thought to be a sound treatment because of improved clearance of uremic toxins and control of extracellular fluid volume. After all, no solute or volume control is tantamount to no dialysis, and whatever its shortcomings, dialysis does keep people alive. The

MO843PREVALENCE AND MANAGEMENT OF HYPERTENSION IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Hypertension (HTN) is common in hemodialysis (HD) patients &amp; diagnosed by pre-dialysis BP &amp;gt;140/90 mmHg. Causes include high salt intake, volume overload, &amp; loss of residual kidney function. Therapy includes achieving correct dry weight with each session, restricting interdialytic sodium &amp; fluid intake &amp; medications. We review its prevalence, factors associated with it &amp; its management in our patients. Method Demographics, HD prescription &amp; medications data collected for patients from 5 dialysis centers. Results A total of 1585 files reviewed. Males were 51.8% &amp; mean age was 59. Mean age significantly higher for females (61 vs 57). ESKD cause was DM in 51% &amp; HTN in 35%. However, of files reviewed, adequate data on comorbidities in 1390 patients (table 1), 69% had DM, 92% had HTN, 47% had CVD &amp; 31% had BMI &amp;gt; 25 (which was significantly more frequent in females). HTN was more likely in older patients, diabetics &amp; females with odds of HTN in females nearly twice the odds of HTN in males &amp; odds of HTN with DM is 2.27 times odds of HTN without DM &amp; one-year increase in age would increase odds of HTN by nearly 4%. Mean pre-HD BP for those with HTN was 143/76 mmHg &amp; for those without HTN was 136/75 mmHg. HD frequency was thrice weekly in 94% &amp; HD duration was &amp;gt; 3.5 hours in only 77% of patients. HDF used in 81.5%. Mean interdialytic weight gain (IDWG) was 2.8 kg, with no difference according to gender or presence of DM or HTN (Table 2). Higher IDWG associated with age &amp;lt; 65, Calcium bath of 1.75 &amp; Sodium bath &amp;gt; 138 with 0.638 kg higher IDWG with calcium of 1.75 compared to calcium of 1.25. Higher IDWG was associated with higher BP. Mean volume of fluid removed per session was 2.74, which was less than mean IDWG, with no difference according to gender or DM, however, it was higher in the higher dialysate sodium group, &amp; lower in the shorter session group (with trend towards statistical significance). CCB used to treat HTN in 62% followed by βB in 52%. Number of patients with HTN on 1 drug 21%, 2 drugs 27%, 3 drugs 23%, ≥ 4 drugs 20% &amp; 9% missing data. Number of antihypertensives did not correlate with IDWG. Conclusion Interdialytic weight gain in our HD patients is excessive &amp; contributing to HTN. Patients must restrict salt &amp; fluid intake &amp; dialysis centers must regularly &amp; frequently assess dry weight, ensure thrice weekly schedule &amp; 4 hours per session are met, so excess fluid is completely removed. Also, high sodium &amp; high calcium baths need to be avoided.

Intradialytic hypotension: is timing everything?

Intradialytic hypotension (IDH) is a major complication of hemodialysis, leading to myocardial stunning, cerebral hypoperfusion, gut ischemia, loss of residual kidney function, high symptom burden, and death. This study by Keane etal. provides new data on the incidence of IDH over well-defined time intervals during the hemodialysis treatment session, clinical parameters associated with the timing of IDH onset, and whether timing of IDH impacts survival in a nationally representative hemodialysis cohort.

Protection of Residual Renal Function and Nutritional Treatment: First Step Strategy for Reduction of Uremic Toxins in End-Stage Kidney Disease Patients.

The retention of uremic toxins and their pathological effects occurs in the advanced phases of chronic kidney disease (CKD), mainly in stage 5, when the implementation of conventional thrice-weekly hemodialysis is the prevalent and life-saving treatment. However, the start of hemodialysis is associated with both an acceleration of the loss of residual kidney function (RKF) and the shift to an increased intake of proteins, which are precursors of uremic toxins. In this phase, hemodialysis treatment is the only way to remove toxins from the body, but it can be largely inefficient in the case of high molecular weight and/or protein-bound molecules. Instead, even very low levels of RKF are crucial for uremic toxins excretion, which in most cases are protein-derived waste products generated by the intestinal microbiota. Protection of RKF can be obtained even in patients with end-stage kidney disease (ESKD) by a gradual and soft shift to kidney replacement therapy (KRT), for example by combining a once-a-week hemodialysis program with a low or very low-protein diet on the extra-dialysis days. This approach could represent a tailored strategy aimed at limiting the retention of both inorganic and organic toxins. In this paper, we discuss the combination of upstream (i.e., reduced production) and downstream (i.e., increased removal) strategies to reduce the concentration of uremic toxins in patients with ESKD during the transition phase from pure conservative management to full hemodialysis treatment.

The effect of extended‐hours hemodialysis on outcomes: A systematic review and meta‐analysis

Extended-hours hemodialysis is associated with improvements in quality of life (QoL) and mortality, but it may accelerate the loss of residual kidney function (RKF) and increase vascular access complications. Multiple established databases were systematically searched; randomized and non-randomized studies were pooled separately. QoL outcomes were assessed using standardized mean difference (SMD), vascular access adverse events and mortality were assessed with relative risk ratios (RR). Four hundred seventy-six patients from six trials were eligible. Data from randomized controlled trials (RCTs) could only be synthesized for vascular access adverse events and mortality, which demonstrated no significant change in vascular access adverse events (RR 1.25, 95% CI 0.88 to 1.77) or mortality (RR 2.29, 95% CI 0.60 to 8.71). Pooled data from non-randomized trials demonstrated no significant difference in QoL (SF-36 Physical Component Summary SMD 0.61, 95% CI -0.10 to 1.31, SF-36 Mental Component Summary SMD -0.04, 95% CI -0.61 to 0.54). RKF was assessed in one report which demonstrated a potential reduction over 12 months with extended-hours hemodialysis. The majority of trials had high risk of bias. Extended-hours hemodialysis was not associated with improved QoL or mortality, or increased vascular access events. Adequately powered RCTs are needed to fully assess extended-hours hemodialysis.